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Case Report

Concurrent supra and infra-tentorial traumaticparenchymal hematomas: Which one needs to beevacuated first?

Amit Agrawal a,*, Surya Pratap Singh b

a Professor, Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem,

Nellore 524003, Andhra Pradesh, IndiabResident, Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem,

Nellore 524003, Andhra Pradesh, India

a r t i c l e i n f o

Article history:

Received 23 February 2013

Accepted 12 May 2013

Available online 28 May 2013

Keywords:

Cerebellar hematoma

Delayed hematoma

Intracerebral hematoma

Delayed traumatic intracerebellar

hematoma

Cerebral contusion

* Corresponding author. Tel.: þ91 8096410032E-mail addresses: dramitagrawal@gmail.

0973-0508/$ e see front matter Copyright ªhttp://dx.doi.org/10.1016/j.ijnt.2013.05.005

a b s t r a c t

Traumatic intra-cerebellar hematoma although uncommon, yet increasing recognized

lesions accounting for 6e0.82% of the total hematomas. We discuss a case of 19-year-old

male multiple simultaneous traumatic supratentorial and infra-tentorial hemorrhages. In

present case presence of significant size hematomas in both supra and infra-tentorial

compartment posed a difficult challenge as which one needs to be evacuated first? This

was a concern in present case as evacuation of the infra-tentorial hematoma can lead to

downward herniation and evacuation of the supratentorial hematoma can lead to upward

herniation. The difficulties and approach for an uncommon case of delayed and multiple

traumatic supra and infra-tentorial hematomas are discussed.

Copyright ª 2013, Neurotrauma Society of India. All rights reserved.

1. Introduction 2. Case report

Traumatic intra-cerebellar hematoma although uncom-

mon, yet increasing recognized lesions accounting for

6e0.82% of the total hematomas.1e6 Multiple simultaneous

traumatic supratentorial and infra-tentorial hemorrhages

are very uncommon.5,6 We discuss the difficulties and

approach for an uncommon case of delayed and multiple

traumatic supra and infra-tentorial hematomas in a young

male.

(mobile).com, dramit_in@yahoo.co2013, Neurotrauma Socie

19-year-old male patient presented with 4 h after the road

traffic accident, while he was driving the motor cycle and

collided with a trolley and crashed into the road divider. He

was in altered sensorium since then. He hadmultiple episodes

of vomiting and left ear bleed. At the time of presentation he

was in altered sensorium (GCS-E2V2M5), pupils were bilateral

equal and reacting. He was moving all four limbs equally.

His general and systemic examination was unremarkable.

m (A. Agrawal).ty of India. All rights reserved.

t h e i n d i a n j o u rn a l o f n e u r o t r a uma 1 0 ( 2 0 1 3 ) 1 3 1e1 3 5132

The patient underwent emergency CT scan brain plain (5 h

post injury) and it showed mild diffuse cerebral edema, right

occipital bone fracture with small underlying cerebellar

contusion and patchy appearance of the left frontal lobe

(Fig. 1). The patient was admitted to intensive care unit and

was started on anti-edema measures and anti-epileptics.

Although his GCS was same but in view of doubtful patchy

lesions a repeat elective CT scan was performed in the

morning (after 18 h pos-injury) and it showed extensive

multiple hemorrhagic contusion involving left frontal and

temporal lobe, right cerebellar hemisphere with significant

mass effect andmidline shift (Fig. 2). The patientwas taken for

emergency evacuation of both supra and infra-tentorial he-

matomas. While the patient was undergoing preparation for

surgery both pupils becamemid-dilated andmildly reactive to

the light. First he underwent evacuation of right paramedian

sub-occipital craniectomy and evacuation of cerebellar he-

matoma. It was followed by left fronto-temporal craniotomy

and evacuation of frontal and temporal intra-cerebral hema-

tomas followed by a lax duraplasty. He was kept on elective

Fig. 1 e CT scan brain 4 h after injury showing only mild cerebra

basal contusion and right occipital bone linear fracture.

ventilation, tracheostomy was performed on 3rd day and he

could be weaned off from ventilator 10-day post surgery. He

made gradual recovery in his neurological status, he was

localizing to pain, opening eyes to call with mild right upper

and lower limbweakness. A follow up CT scan total resolution

of cerebellar and frontal hematomas and resolving temporal

hematoma with reduction in mass effect and midline shift

(Fig. 3).

3. Discussion

With the increasing availability of the CT scan, delayed trau-

matic intracerebral hematoma (DTICH) diagnosed only

sporadically in the past is now a well-established clinical

entity.1,7e14 In patients with delayed traumatic cerebellar he-

matomas few risk factors have been identified and include

scalp contusion or laceration over the occiput, a suture line

separation or fracture line traversing the lateral sinus or

extending through the foramen magnum,2,5,15 when a

l edema, small right cerebellar contusion, patchy left frontal

Fig. 2 e CT scan 18 h after post injury showing extensive contusion involving right cerebellar hemisphere, left frontal and

temporal lobe with significant mass effect and midline shift including distortion of 4th ventricle and brain stem (because of

cerebellar contusion).

t h e i n d i a n j o u r n a l o f n e u r o t r a uma 1 0 ( 2 0 1 3 ) 1 3 1e1 3 5 133

patient’s clinical condition fails to improve or deteriorates

after the appropriate therapeutic measures,15 elderly pa-

tients.16 and injury had been sustained with the head in mo-

tion.9,11 These lesions develop several hours to days after

trauma and can be demonstrated and followed up by serial CT

scans.10,11,16,17 This dynamic and expansile nature of cerebral

contusions can lead to rise in intracranial pressure and

delayed neurological deterioration.18 The mechanism for the

expansion of hematoma are not well understood and many

explanations have been proposed including latent coagulop-

athy leading to continued or delayed bleeding of microvessels

and delayed formation of petechial hemorrhages which then

coalesce to produce hemorrhagic progression.16,19e21

Expanding lesions either in the supratentorial compartment

or infra-tentorial compartment can cause compression of

cerebral and cerebellar hemispheres and subsequent distor-

tion (including downward or upward shift brain stem struc-

tures) of adjacent structures resulting in spectrum of clinical

manifestations (tentorial herniation, brain stem ischemia,

tonsillar herniation, third nerve compression and so on).22e24

Prompt evacuation of the large and expanding lesions with

poor Glasgow coma scale has been associated with favorable

outcome.1,3e6,21,25e27 In present case the presence of signifi-

cant size hematomas in both supra and infra-tentorial

compartment posed a difficult challenge as all the hema-

tomas were needed evacuation but the difficult in making a

decision that which one needed to be evacuated first? This

was a concern in present case as evacuation of the infra-

tentorial hematoma can lead to downward herniation and

evacuation of the supratentorial hematoma can lead to up-

ward herniation with its sequele.28e30 It has been well recog-

nized that acute pupillary dilation in a traumatic brain injury

patient is usually due to uncal herniation causing mechanical

compression of the 3rd cranial nerve and subsequent brain

stem compromise.31 However in alternative hypotheses it has

been postulated that a decrease in brain stem blood flow also

can cause of mydriasis and can be rapidly restored once the

compression from the brain stem is removed.31 Pupillary size

and reaction to light helped us to make a decision. As the

pupils were mid-dilated and sluggishly reacting to light it was

Fig. 3 e Follow up CT scan at 2 weeks showing good resolution of cerebellar and frontal hematomas and resolving left

temporal lobe hematoma, please note significant resolution of the mass effect and midline shift.

t h e i n d i a n j o u rn a l o f n e u r o t r a uma 1 0 ( 2 0 1 3 ) 1 3 1e1 3 5134

presumed that probably it was due to brain stem compression

and ischemia. Once the posterior fossa hematoma was evac-

uated pupils became normal in size and were reacting to light

even before the supratentorail hematoma could be evacuated.

In summary, there may be delayed development of con-

current supra and infra-tentorial traumatic parenchymal he-

matomas leading to neurological deterioration of the patient.

Making a decision which hematoma needs to be evacuated

can be difficulty. In these cases imaging findings and clinical

picture of the patient can help to make a decision that which

one needs to be evacuated first? As a rule of thumb, unless the

supratentorial is very large and toward the midline, infra-

tentorial hematoma needs to be evacuated first, if the lesions

are on either side of the tentorium (supra and infratentorial

compartment) a combined approach for evacuation may be

performed. Also as long as both the hematomas are evacuated

in the same general anesthesia patient is safe (even when

supratentorial hematoma is evacuated first because of the

sheer larger size).

Conflicts of interest

All authors have none to declare.

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